GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 362 072 ▪ ombudsman.gov.au
Permission for another person to act on my behalf
If you would like another person, who is not your legal guardian or legal representative, to act on
your behalf and communicate with the VET Student Loans Ombudsman (VSLO) about your
complaint, you must provide your consent. To do so you can:
• complete and return this form to this Office either by e-mail to VET@ombudsman.gov.au
; or
• contact the Ombudsman’s Office on 1300 362 072; or
• by letter to GPO Box 442, Canberra ACT 2601.
Your contact information Reference Number (if known):___________________________
Name: ________________________________________________ Date of Birth: _______________
Phone: ___________________________ Email: __________________________________________
Postal Address: _______________________________________________________ Postcode: ___________
The contact information of the person authorised to act on your behalf
Name:
________________________________________________ Date of Birth: _______________
Phone: ___________________________ Email: __________________________________________
Postal Address: _______________________________________________________ Postcode: ___________
Relationship: ____________________________________________________________________________
I, …………………………..……………………………………… consent to ……………….…………………………………………………
[your name] [name of authorised person]
disclosing my personal information to the VSLO in order to resolve a complaint about a matter
between me and .......................................................................................... .
[name of the department/agency/provider you are complaining about]
I understand that ……………….………………………………………………… will receive personal information from
[name of authorised person]
the VSLO about my complaint.
☐ I consent for the VSLO to contact me to discuss circumstances surrounding my matter if it is
deemed necessary.
☐ I acknowledge that I can withdraw my consent for the nominated person to act on my
behalf, at any time, by contacting the VSLO.
Your signature ................................................................... Date ................................................
